Alumni association directory update

Please fill out the information requested below and mail or fax this form to the alumni association to ensure that the next alumni directory is accurate and up-to-date.

Name

• First name
• Middle name
• Last name
• Nick name

Spouse

• First name
• Middle name
• Last name
• Nick name

Office address

• Street address
• City
• State
• Zip

Home address

• Street address
• City
• State
• Zip

Office telephone ________________________

Office fax ______________________

Home telephone ________________________

Home fax _____________________

email address _____________________________________

Degree [DDS or RDH] __________________

Year of graduation ____________

Postgraduate degree/certificate ___________

Degree year _________________

Specialty ________________________________________________________

Professional license # ________________________

Mail to:

LLUSD Alumni Association
11092 Anderson Street
Loma Linda, CA 92354

Or fax: (909) 558-4858

LLU SD HOME | ALUMNI HOME